Upper Extremity Rehabilitation using Robotics

 Description 

Robotic upper limb rehabilitation therapy has been gaining traction in the rehabilitation field as technology advances. It is used to supplement or facilitate rehabilitation by assisting in the repetitive labor-intensive manual therapy that are normally administered by therapistsZariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104. This decreases the time demands on therapists as the robotic devices can help move the patient’s limbs during exercises, thereby increasing the amount of therapy for each patient and increasing the number of patients undergoing therapy simultaneously Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104.

There are two main types of robotic devices for upper limb rehabilitation: the end-effector-based and the exoskeleton- based robots. The main advantage of the end-effector system is that it adapts to patients with different body sizes. In contrast, the exoskeleton upper limb robot requires various modifications in different patients because they need an optimal joint adaptation to work correctly Sale P, Mazzoleni S, Lombardi V, Galafate D, Massimiani MP, Posteraro F, et al. Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial. Int J Rehabil Res [Internet]. 2014;37(3):236–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24769557. Examples of the types of robotic devices are: The T-WREX Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104 Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96., the ARMin Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104, the MIME Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104 Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96., the ARM guide Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104 Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96., the Bi-Manu-Track Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104, the GENTLE/s Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104 and the Armeo Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104 Colomer C, Baldoví A, Torromé S, Navarro MD, Moliner B, Ferri J, et al. Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia [Internet]. 2013;28(5):261–7. Available from: files/160/495v28n05a90209825pdf001.pdf%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/22727271 Longhi M, Merlo A, Prati P, Giacobbi M, Mazzoli D. Instrumental indices for upper limb function assessment in stroke patients: a validation study. J Neuroeng Rehabil [Internet]. 2016;13(1):52. Available from: http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0163-4, the Amadeo Sale P, Mazzoleni S, Lombardi V, Galafate D, Massimiani MP, Posteraro F, et al. Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial. Int J Rehabil Res [Internet]. 2014;37(3):236–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24769557.

Indication 

The hand serves very important role with functionality. It is used in everyday activities such as eating, dressing, object manipulation and handwriting. Therefore, re-training reach and grasping skills is critical to improving quality of life and hand therapy is used to re-learn these basic skills. Upper-extremity impairment is the most significant disability in stroke survivors as it is reported in about 70% of patients on admission of a stroke Longhi M, Merlo A, Prati P, Giacobbi M, Mazzoli D. Instrumental indices for upper limb function assessment in stroke patients: a validation study. J Neuroeng Rehabil [Internet]. 2016;13(1):52. Available from: http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0163-4. Patients with Parkinson’s and Multiple Sclerosis also often have upper limb dysfunction. Emerging evidence shows that robotics can be useful in these populations as well Gijbels D, Lamers I, Kerkhofs L, Alders G, Knippenberg E, Feys P. The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study. J Neuroeng Rehabil [Internet]. 2011;8(1):5. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3037310&tool=pmcentrez&rendertype=abstractPicelli A, Tamburin S, Passuello M, Waldner A, Smania N. Robot-assisted arm training in patients with Parkinson ’ s disease : a pilot study. 2014;24–7.. Hemiparesis is often seen in spinal cord injuries where the right or the left side of the upper limbs are affected. A full or even partial recovery depends on repetition, intensity and task-orientation Longhi M, Merlo A, Prati P, Giacobbi M, Mazzoli D. Instrumental indices for upper limb function assessment in stroke patients: a validation study. J Neuroeng Rehabil [Internet]. 2016;13(1):52. Available from: http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0163-4. Hence, within good reason, the use of robotics to increase the amount of motor repetitions can aid in recovery Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104. The dose-response relationship in stroke rehabilitation has showed that the more intensive therapies are associated with a greater rate of motor recovery with no ceiling effect being observed Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96..

Despite what the research shows, traditional hands on therapy are not delivered with a high enough frequency and intensity because of labor limitations and cost Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. Traditional therapies can also result in repetitive strain injuries and fatigue by therapists Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. The variability between therapists are also factors that could affect or lead to inconsistent outcomes Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. The advanced robotic devices are capable of providing consistent training to measure performance with high reliability and accuracy Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. Above all, the robotics can permit patients to train independently with less supervision from a therapist Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96..

Key Evidence 

Stroke and Spinal Cord Injuries 

Several robotic machines have shown to be effective in patients with stroke. For example, the Armeo Spring  helps to recover function in the hemiparetic arm, forearm and wrist in patients who have experienced a stroke and have consequent hemiparesis. The Armeo Spring is an adjustable suspension system for the upper limb that connects to virtual reality (VR), which has settings with several degrees of complexity Colomer C, Baldoví A, Torromé S, Navarro MD, Moliner B, Ferri J, et al. Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia [Internet]. 2013;28(5):261–7. Available from: files/160/495v28n05a90209825pdf001.pdf%5Cn http://www.ncbi.nlm.nih.gov/pubmed/22727271. The system is an exoskeleton that supports the patient’s arm and magnifies any residual active movement of the hemiparetic arm in 3-dimensional space Colomer C, Baldoví A, Torromé S, Navarro MD, Moliner B, Ferri J, et al. Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia [Internet]. 2013;28(5):261–7. Available from: files/160/495v28n05a90209825pdf001.pdf%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/22727271. Distally, it detects grasp pressure and the sensitivity may be adjusted depending on the patient’s condition Colomer C, Baldoví A, Torromé S, Navarro MD, Moliner B, Ferri J, et al. Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia [Internet]. 2013;28(5):261–7. Available from: files/160/495v28n05a90209825pdf001.pdf%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/22727271. VR settings are designed to bring varying levels of difficulty in the velocity, direction and moving area Colomer C, Baldoví A, Torromé S, Navarro MD, Moliner B, Ferri J, et al. Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia [Internet]. 2013;28(5):261–7. Available from: files/160/495v28n05a90209825pdf001.pdf%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/22727271. The system provides information about specific movement parameters (strength, range of motion, and coordination) to allow for proper adjustment of the difficulty level for the patient during the recovery process Colomer C, Baldoví A, Torromé S, Navarro MD, Moliner B, Ferri J, et al. Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia [Internet]. 2013;28(5):261–7. Available from: files/160/495v28n05a90209825pdf001.pdf%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/22727271. A study of the effects of the Armeo spring system and the benefits in subacute spinal cord injury patients showed that there is significant improvement in the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) sensibility scores of subjects with partial hand function at baseline Zariffa J, Kapadia N, Kramer JLK, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, et al. Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population. IEEE Int Conf Rehabil Robot [Internet]. 2011;50(3):220–6. Available from: http://dx.doi.org/10.1038/sc.2011.104.

Specific to the fingers and hand, the Amadeo is another robotic system that has shown to be useful in those recovering from stroke. A randomized control trial conducted on acute stroke patients looked at the effectiveness of robot- assisted hand therapy using the Amadeo Robotic System by Tyromotion. Amadeo Robot is an end-effector based system that has five degrees of freedom and provides the motion of one or all five fingers through a passive rotational joint placed between the fingertip and an entity that moves laterally (the thumb has two passive rotational joints) Sale P, Mazzoleni S, Lombardi V, Galafate D, Massimiani MP, Posteraro F, et al. Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial. Int J Rehabil Res [Internet]. 2014;37(3):236–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24769557. All five translational degrees of freedom are independent and provide an almost entire coverage of the fingers’ workspace Sale P, Mazzoleni S, Lombardi V, Galafate D, Massimiani MP, Posteraro F, et al. Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial. Int J Rehabil Res [Internet]. 2014;37(3):236–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24769557. The interface between the human hand and the machine is achieved thanks to elastic bands or plasters and the wrist is restrained from movement by a Velcro strap Sale P, Mazzoleni S, Lombardi V, Galafate D, Massimiani MP, Posteraro F, et al. Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial. Int J Rehabil Res [Internet]. 2014;37(3):236–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24769557. The Amadeo treatment composed of:
1) Continuous passive therapy
2) Assisted movement therapy
3) Balloon training (active training in a virtual environment by carrying out target oriented tasks) Sale P, Mazzoleni S, Lombardi V, Galafate D, Massimiani MP, Posteraro F, et al. Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial. Int J Rehabil Res [Internet]. 2014;37(3):236–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24769557.
Comparable to traditional Occupational Therapy methods, patients within the robotic therapy group made significant improvements in Fugl-Meyer Scale (FM), and Box and Block Test (BB) at the end of treatment (4/5 weeks) and maintained improvements after a 3-month follow-up Sale P, Mazzoleni S, Lombardi V, Galafate D, Massimiani MP, Posteraro F, et al. Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial. Int J Rehabil Res [Internet]. 2014;37(3):236–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24769557. This result is very important because the gain achieved is not exercise or time dependent, but could be secondary to reorganization of brain structures Sale P, Mazzoleni S, Lombardi V, Galafate D, Massimiani MP, Posteraro F, et al. Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial. Int J Rehabil Res [Internet]. 2014;37(3):236–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24769557.

More evidence demonstrated the clinical feasibility of using other types of robotics than the Armeo or Amadeo. MIT-MANUS, MIME, ARM-Guide, T-WREX and NeReBot Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. The results are just as expected, when conventional therapy is matched with robotic therapy in terms of duration/intensity, there is no statistically significant difference in the Fugl Meyer assessment scores Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. However, when robotic therapy was added on top of conventional therapy, there was a significant improvement in Fugal Meyer scores Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. The same results were seen in motor control measured by the Motor Status Scale. The presiding theme that more is better exists whether it is therapy is conventional or roboticNorouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. However, functional abilities (measured by the FIM) did not see the same improvements with additional robotic therapy Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. This difference can be attributed to the fact that robotic therapy programs focus mainly on motor recovery rather than functional abilities of the upper limb Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96.. This can have a negative impact on treatment as patients participate in rehabilitation to try to regain functional abilities and they want to see better results in that regard.

https://www.youtube.com/watch?v=zE-NmOw-uY4Armeo Spring Video                                                        https://www.youtube.com/watch?v=KA37ws_6-XMAMADEO Finger-Hand-Rehabilitation

Multiple Sclerosis

Limited evidence has also shown the Armeo Spring to be an effective rehabilitation tool in those with Multiple Sclerosis (MS). While no changes in muscle strength were observed, functional capacity tests significantly improved after treatment, and improvements were maintained at 2 month follow up Gijbels D, Lamers I, Kerkhofs L, Alders G, Knippenberg E, Feys P. The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study. J Neuroeng Rehabil [Internet]. 2011;8(1):5. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3037310&tool=pmcentrez&rendertype=abstract. It is important to note that these patients were considered to have an elevated level of upper limb disability. More recent research using the HapticMaster robot combined with a virtual reality system showed positive effects on perceived function in MS patients, but no significant clinical changes at the group level Feys P, Coninx K, Kerkhofs L, De Weyer T, Truyens V, Maris A, et al. Robot-supported upper limb training in a virtual learning environment : a pilot randomized controlled trial in persons with MS. J Neuroeng Rehabil [Internet]. 2015;12(1):60. Available from: http://www.jneuroengrehab.com/content/12/1/60. However, when researchers observed their raw data, they noticed that those with upper limb function considered marked-to- severe did show considerable improvement on clinical tests Feys P, Coninx K, Kerkhofs L, De Weyer T, Truyens V, Maris A, et al. Robot-supported upper limb training in a virtual learning environment : a pilot randomized controlled trial in persons with MS. J Neuroeng Rehabil [Internet]. 2015;12(1):60. Available from: http://www.jneuroengrehab.com/content/12/1/60.

Parkinson's Disease

Most research on robotics in Parkinson’s rehabilitation seems to be related to gait. However, one 2004 study examined the effects of the <a href="http://www.reha-stim.de/cms/index.php?id=60">Bi-Manu-Track</a> robot on upper limb function. After ten, 45-minute treatment sessions with the robot, patients showed significant changes in the <a href="http://www.physio-pedia.com/Nine-Hole_Peg_Test">nine-hole peg test</a> and the upper limb portion of the <a href="Fugl-Meyer Assessment of Motor Recovery after Stroke">Fugl-Meyer</a>. At two-week follow up, improvements in the nine-hole peg test were still present Picelli A, Tamburin S, Passuello M, Waldner A, Smania N. Robot-assisted arm training in patients with Parkinson ’ s disease : a pilot study. 2014;24–7.. Although this is just the results of one study with a small sample size (n=10), it seems to be a promising area of research.

Assessment Tool

The Armeo has also been shown to be a valid measurement tool to access upper limb movement performance in sub-acute stroke patients Longhi M, Merlo A, Prati P, Giacobbi M, Mazzoli D. Instrumental indices for upper limb function assessment in stroke patients: a validation study. J Neuroeng Rehabil [Internet]. 2016;13(1):52. Available from: http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0163-4. Construct validity has been proven for the hand patio, the mean velocity and the number of peaks in the velocity profile which accesses the movement accuracy, velocity and smoothness respectively Longhi M, Merlo A, Prati P, Giacobbi M, Mazzoli D. Instrumental indices for upper limb function assessment in stroke patients: a validation study. J Neuroeng Rehabil [Internet]. 2016;13(1):52. Available from: http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0163-4. So an accurate initial assessment test using robotics such as Armeo spring can be done and training with the robot can demonstrate improvement and have a valid post test to evaluate treatment Longhi M, Merlo A, Prati P, Giacobbi M, Mazzoli D. Instrumental indices for upper limb function assessment in stroke patients: a validation study. J Neuroeng Rehabil [Internet]. 2016;13(1):52. Available from: http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0163-4.

Contributors

This page was created by Queen's University Physiotherapy students <a href="http://www.physio-pedia.com/User:Michael_Richards">Michael Richards</a>, <a href="http://www.physio-pedia.com/User:Bentzen_Takyi">Bentzen Takyi</a>, and Richard Iheadindu.